Dear <<Cli_FirstNames:PC>>,

Re: Insurance Policies with <<Agncy_Name>>


I give permission for <<Agncy_Name>> to discuss my insurance policies with my <<Input:explain relationship - son/daughter/parent/friend>>, <<Input:Enter the name of this person>>. If I am unavailable, they have my permission to discuss the policy details and/or make any necessary changes to the policy.


This authorization is good for <<Input:Enter Period of time or indefinite>>.






Please return this signed form to my agency as soon as possible. We can not discuss your account with anyone other than the named insureds on the policy unless this form is on file.


<<User Name>>
<<Agncy_Address>>, <<Agncy_City>>, <<Agncy_State>>  <<Agncy_Zip>>
Phone:<<Agncy_Phone>>  |  Fax: <<Agncy_Fax>>